HESI EAQ week4

Which assessment finding of the skin refers to elasticity? 1 Turgor2 Edema3 Texture4 Vascularity

1 Turgor

A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific c for this diagnosis?

Edrophonium chloride test

Which foot disorder is caused by continual pressure over bony prominences? 1Corn 2Wart 3Hammertoe 4Hallux rigidus

1 Corn A corn is a foot disorder caused by continual pressure over bony prominences. A plantar wart is a foot disorder caused by a virus. Hammertoe is a foot disorder caused by flexion and deformity in the joints. Hallux rigidus is caused by osteoarthritis.

What is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number. _____ cm

10

After a 4-year-old child undergoes craniotomy the nurse performs a neurologic assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment?1Blood pressure2Motor function3Rectal temperature4Head circumference

2

The nurse is educating new parents about circumcision. Which structure of the penis would this nurse tell the parents is removed during circumcision?1 Glans2 Prepuce3 Epididymis4 Vas deferens

2 Prepuce Circumcision is a procedure that involves removal of the prepuce, a skin fold over the glans. The glans is the tip of the penis. The epididymis is the internal structure that promotes transportation of the sperm. The vas deferens carries the sperm from the epididymis to the ejaculatory duct.

Which bones are examples of a client's flat bones? Select all that apply. One, some, or all responses may be correct.1Sacrum2Scapula3Sternum4Humerus5Mandible

2,3 Flat bones such as the scapula and sternum are compact bones separated by a layer of cancellous bone that contains bone marrow. Bones such as the sacrum and mandible are irregular bones; they appear in a variety of shapes and sizes. The humerus is a long bone with a central shaft and two widened ends.

A client injures an amphiarthrodial joint. Which joint did the client injure? 1Knee joint 2Pelvic joint 3Elbow joint4 Cranial joint Amphiarthrodial joints are those that permit slight movements. The pelvic joint is an example of amphiarthrodial joint. Knee and elbow joints are the examples of diarthrodial joints, which are freely movable. A cranial joint is an example of a synarthrodial joint, which is immovable.

2Pelvic joint

Which radiographic test is used to view the entire skeleton? A. Bone scan B. Gallium and thallium scan C. Computed tomography (CT) D. Magnetic resonance imaging (MRI) scan

A. Bone scan A bone scan is a radionuclide test in which radioactive material is injected so that the client's entire skeleton can be viewed. Gallium and thallium scans are similar to bone scans but are more specific and sensitive in detecting bone disorders. A CT scan is used to detect musculoskeletal problems, primarily in the vertebral column and joints. An MRI scan is used to diagnose musculoskeletal disorders.

Nursing care for a child admitted with acute glomerulonephritis should be directed towards: a. enforcing bed rest b. promoting diuresis c. encouraging fluids d. removing dietary salt

B

Which clinical finding would the nurse associate with hypokalemia? 1 Edema 2 Muscle spasms 3 Kussmaul respirations 4 Muscle weakness

4 Muscle weakness

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition?

4+ Edema of 8 mm is documented as 4+. If the edema has a depth of 2 mm, then it is documented as 1+. If the edema has a depth of 4 mm, it is documented as 2+. If the edema has a depth of 6 mm, then it is documented as 3+.

Which condition can be identified in a client using Phalen's test?1Atrophy2Bone tumor3Rotator cuff injury4Carpal tunnel syndrome

4Phalen's test is used to detect carpal tunnel syndrome. A muscle biopsy is done for the diagnosis of atrophy. A computed tomography scan is done to diagnose a bone tumor. The drop arm test is performed to detect rotator cuff injuries.

Which type of joint permits movement in any direction?

Ball-and-socket joints

Aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis. The nurse understands that the drug is being used primarily for which of its properties? 1Analgesic 2Antipyretic 3Antiinflammatory 4Antiplatelet

Antiinflammatory

What procedure is done for direct visualization of the ligaments, menisci, and articular surfaces of the joints?

Arthroscopy

Which complications would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries?

Autonomic hyperreflexia

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How should the nurse respond when the client complains of pain and requests medication?

By acknowledging that the pain is real and administering medication to relieve it

Which test provides information on bladder capacity, bladder pressure, and voiding reflexes?

Cystometrography (CMG)

Which professional standard does the nurse feel is most important for critical thinking?

Evaluation Criterion An evaluation criterion is an important professional standard required for critical thinking. Logical thinking, accurate knowledge, and relevant information are important intellectual standards required for critical thinking.

A client who is taking rifampin (Rifadin) tells the nurse, "My urine looks orange." What action should the nurse take?

Explain its expected Rifampin causes a reddish orange discoloration of secretions such as urine, sweat, and tears. While liver enzymes should be monitored because of the risk of hepatitis, this action is not addressing the client's statement. Straining the urine for stones is indicated for renal calculi, which are not related to rifampin. The medication, not food, is responsible for the urine color.

A nurse provides discharge teaching to a client who had a total hip replacement. The client states that the plan is to go swimming at the community pool the day after discharge. How should the nurse respond?

Explain that the incision should not be immersed in water until it has healed.

Which statement defines the term family resiliency?

Family resiliency is the ability of the family to cope with stressors

A patient who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, what is the best nursing intervention in this situation? a. Immediately involve pastoral services while caring for the patient. b. Involve the family member in the patient's care instead of pastoral support. c. Listen to the patient's request for support then carry on with the clinical work. d. Falsely promise that pastoral services has been contacted and plan to see the patient.

Immediately involve pastoral services while caring for the patient.

Which structure connects the client's tibia to the femur at the knee joint?1Fascia2Bursae3Tendons4Ligaments

Ligaments

Which term would the nurse document in the client's medical record after observing reduced urinary output?

Oliguria (Explanation: A reduced urinary output of less than 400 mL in a 24-hour interval is called oliguria. Anuria is the absence of urination. Painful or difficult urination is called dysuria. Frequent urination at night is called nocturia.)

What term does the nurse explain is used for the tip of the pyramid of a kidney?

Papilla

When obtaining a health history from a client recently diagnosed with type 1 diabetes, the nurse expects the client to report which clinical manifestation?

Polyuria

Which position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties? 1Sims position 2Prone position 3Supine position 4Knee-chest position

Prone position

Which retrograde procedure involves the examination of the ureters and the renal pelvises?1. Cystogram2. Pyelogram3. Urethrogram4. Voiding cystourethrogram

Pyelogram A pyelogram is a retrograde examination of the ureters and the pelvis of both kidneys. A cystogram is a retrograde examination of the bladder. An urethrogram is a retrograde examination of the urethra. A voiding cystourethrogram is used to determine whether urine is flowing backward into the urethra.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day. (Spacing activities will encourage maximum functioning within the limits of strength and fatigue.)

Best place to look for jaundice

The sclera is the best site to inspect for jaundice. Because the skin may become pale due to anemia or jaundice, a skin inspection is not recommended.

Which diagnostic study would the healthcare provider use to investigate the cause of an inflamed joint and determine a clients response to anti-inflammatory medication therapy?

Thermography

Which assessment is expected when a client is placed in the lithotomy position during physical examination?

To assess the female genitalia Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims position are recommended for clients undergoing rectal examinations. The prone position is indicated in clients to assess the musculoskeletal system.

synovial join movement away from midline

abduction

Which joint helps in the gliding movement of the wrist?

biaxial joint

Which type of bone tumor is commonly seen in elderly clients?

chondrosarcoma

Which critical thinking skill in nursing practice requires the nurse to possess knowledge and experience for choosing care strategies for clients?

explanation

which part of the kidney senses changes in blood pressure

macula densa

Which estrogen antagonist would the health care provider prescribe a client for the prevention and treatment of osteoporosis in postmenopausal women?

raloxifene